Adjuvant systemic therapy in resectable non-small cell lung cancer
- Nasser Hanna, MD
Nasser Hanna, MD
- Indiana University
- Section Editors
- Rogerio C Lilenbaum, MD, FACP
Rogerio C Lilenbaum, MD, FACP
- Section Editor — Lung Cancer
- Yale Cancer Center
- James R Jett, MD
James R Jett, MD
- Section Editor — Lung Cancer
- Professor of Medicine Emeritus
- National Jewish Health
Patients with stage I, II, or IIIA (table 1) non-small cell lung cancer (NSCLC) are at substantial risk for recurrence and death even after complete surgical resection. Approximately 40 to 50 percent of patients with stage IB, 55 to 70 percent of stage II, and a greater percentage of those with stage IIIA NSCLC eventually recur and die of their disease despite potentially curative surgery. (See "Tumor, Node, Metastasis (TNM) staging system for lung cancer".)
The development of active platinum-based combinations and the completion of large clinical trials assessing the activity of adjuvant chemotherapy for resected NSCLC have led to the use of adjuvant chemotherapy to improve the outcome in patients with completely resected NSCLC.
The role of adjuvant systemic therapy for patients with completely resected NSCLC will be reviewed here. Other aspects of the initial treatment of patients with stages I, II, and III NSCLC are discussed separately. (See "Management of stage I and stage II non-small cell lung cancer" and "Management of stage III non-small cell lung cancer".)
Generally, patients with a high risk of recurrence are most likely to derive benefit from chemotherapy, while those who have a low risk of relapse have a lower absolute benefit. Tumor, Nodes, Metastases (TNM) staging is the most important prognostic factor determining the likelihood of relapse and therefore predicts those most likely to benefit from adjuvant therapy. The Tumor, Node, Metastasis (TNM) staging system is used for treatment planning and prognostic purposes in patients with non-small cell lung cancer (NSCLC). The eighth edition will replace earlier editions of the TNM staging system in the United States beginning January 1, 2018 (table 2 and table 1). However, outside of the United States, the Union for International Cancer Control (UICC) has implemented the eighth edition changes as of January 1, 2017. Differences in TNM groupings between the seventh and eighth editions are shown in the table (table 3). Adjuvant chemotherapy is not indicated for patients with resected stage IA disease. Discussion of the approach according to stage is found below. Discussion of prognosis according to stage is found elsewhere. (See "Tumor, Node, Metastasis (TNM) staging system for lung cancer", section on 'Prognosis by stage'.)
Additionally, a number of molecular biomarkers to predict who may benefit from adjuvant chemotherapy are under study and are discussed below. (See 'Investigational strategies' below.)
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- PATIENT SELECTION
- Stage I
- - Stage IA disease
- - Stage IB disease
- Stage II and IIIA disease
- Stage IIIB and higher
- Special considerations
- - Patients requiring surgery and radiation
- - Older adult patients
- - Patients receiving neoadjuvant treatment
- ADMINISTRATION OF CHEMOTHERAPY
- Choice of chemotherapy regimen
- - Cisplatin-based doublets
- - Rationale for use of cisplatin over carboplatin
- Timing of chemotherapy
- Toxicities and quality of life
- Monitoring and post-treatment follow-up
- INVESTIGATIONAL STRATEGIES
- Predictive biomarkers
- Molecularly targeted agents
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS